Illuminating soft tissue retractor

ABSTRACT

The present invention provides a retractor for providing surgical access through a passage in tissue, together with methods for its use and deployment. The retractor comprises an anchoring frame having an upper surface, a lower surface, and an opening therethrough which defines an axial axis. A flexible tensioning member is attached to the frame, and is extendable from the frame out of the body through the passage when the frame is positioned through the passage and into a body cavity. This tensioning member is selectively tensionable to spread the tissue radially outwardly from the axial axis. Hence, it is the tension imposed on the flexible liner which effects retraction of the tissue, rather than relying on the structural integrity of an artificial lumen.

This application is a divisional of U.S. application Ser. No.08/610,619, now U.S. Pat. No. 5,810,721, filed Mar. 4, 1996. Thecomplete disclosure of this related U.S. patent application is herebyincorporated herein by reference for all purposes.

BACKGROUND OF THE INVENTION Field of the Invention

The present invention relates generally to minimally invasive and lessinvasive surgical access. More particularly, the present inventionprovides retractors for soft tissues and methods for their use toprovide surgical access into body cavities.

Coronary artery disease remains the leading cause of morbidity andmortality in western societies. Coronary artery disease is manifested ina number of ways. For example, disease of the coronary arteries can leadto insufficient blood flow resulting in the discomfort and risks ofangina and ischemia. In severe cases, acute blockage of coronary bloodflow can result in myocardial infarction, leading to immediate death ordamage to the myocardial tissue.

A number of approaches have been developed for treating coronary arterydisease. In less severe cases, it is often sufficient to treat thesymptoms with pharmaceuticals and lifestyle modification to lessen theunderlying causes of disease. In more severe cases, the coronaryblockage can often be treated endovascularly using techniques such asballoon angioplasty, atherectomy, or stents.

In cases where pharmaceutical treatment and/or endovascular approacheshave failed or are likely to fail, it is often necessary to perform acoronary artery bypass graft procedure using open surgical techniques.Such techniques require that the patient's sternum be opened and thechest be spread apart to provide access to the heart. A source ofarterial blood is then connected to a coronary artery downstream from anocclusion, while the patient's heart is maintained under cardioplegiaand circulation is supported by cardiopulmonary bypass. The source ofblood may be a vessel taken from elsewhere in the body such as asaphenous vein or radial artery, or an artery in the chest or abdomensuch as the left or right internal mammary artery or the gastroepiploicartery. The target coronary artery can be the left anterior descendingartery, right coronary artery, circumflex artery, or any other coronaryartery which might be narrowed or occluded.

While very effective in many cases, the use of open surgery to performcoronary artery bypass grafting is a highly traumatic to the patient.The procedure requires immediate post-operative care in an intensivecare unit, a total period of hospitalization of seven to ten days, and arecovery period that can be as long as six to eight weeks.

Recently, it has been proposed to utilize minimally invasive surgicaltechniques and procedures to perform coronary artery bypass grafting andother traditionally open-chest cardiac surgical procedures. A widevariety of laparoscopic, arthroscopic, endovascular, and other minimallyinvasive surgical therapies have been developed. These proceduresgenerally utilize trocars, cannulas, catheters, or other tubular sheathsto provide an artificial lumen, through which specialized tools areinserted and manipulated by the surgeon.

An exemplary minimally invasive bypass method is described in U.S. Pat.No. 5,452,733, assigned to the assignee of the present application, thefull disclosure of which is herein incorporated by reference. Thisexemplary coronary artery bypass method relies on viewing the cardiacregion through a thoracoscope and endovascularly portioning thepatient's arterial system at a location within the ascending aorta. Thebypass procedure is performed under cardiopulmonary bypass andcardioplegia, while the coronary anastomoses are formed within the chestcavity through the use of a plurality of trocar sheaths placed betweenthe patient's ribs.

Although thoracoscopic methods hold great promise for decreasingmorbidity and mortality, cost, and recovery time when compared toconventional open surgical coronary bypass procedures, these methodscould benefit from still further improvements. In particular, thesurgical access provided by known trocar sheaths has not been optimallyadapted for performing thoracoscopic coronary artery bypass. The lengthof conventional trocar sheaths and the small size of their lumens limitsthe maneuverability of surgical instruments and inhibits the ability tolook directly into the chest cavity while an instrument is positionedthrough the trocar sheath.

It would therefore be desirable to provide improved surgical accessdevices and methods for their use in performing less invasive coronaryartery bypass grafting and other thoracoscopic surgical procedures, andminimally invasive surgical procedures in general. It would beparticularly desirable if such devices and techniques providedatraumatic retraction of soft tissue of the chest wall to create thelargest possible surgical access window without resorting to asternotomy or gross retraction or removal of the ribs. Preferably, suchimproved surgical access devices and methods would provide a flexibleaccess lumen which could be positioned and sized to meet the individualpatient's physiology. The devices should have minimum height so as toextend as little as possible from the inner or outer surfaces of thechest wall. It would further be desirable if such access devices andmethods allowed direct or magnified viewing of the internal procedurefrom outside the patient body, thereby decreasing the time and traumaassociated with the internal surgical procedure, and increasing overallefficacy over both open surgical procedures and minimally invasivesurgical procedures performed through the small trocar sheaths whichhave been relied on in the prior art.

DESCRIPTION OF THE BACKGROUND ART

Conventional thoracoscopic techniques are described in Landreneau et al.(1992) Ann. Thorac. Surg. 54:800-807. Conventional open surgicalprocedures for performing coronary artery bypass grafting are describedin Kirkland and Barratt Boyes, Cardiac Surgery, John Wiley and Sons,Inc., New York, 1993 (2nd Ed.).

A minimally invasive method for performing coronary artery bypassgrafting using an anterior mediastinotomy, including excision of eitherthe third or fourth costal cartilage, was described by Robinson et al.in J. Card. Surg. (1995) 10:529-536.

U.S. Pat. No. 5,391,156 describes a flexible endoscopic surgical porthaving a tubular body, the outer end of which is optionally divisibleinto a plurality of flaps, thereby matching the length of the tubularbody with the thickness of a body wall. A retainer ring engages theflaps to hold the port axially, while the hoop strength of the tubularbody holds the adjacent tissue in a retracted position. U.S. Pat. No.4,274,398 describes a surgical retractor having elastic tubes which holdhooks under radial tension from a notched frame. U.S. Pat. Nos.4,430,991, and 4,434,791, describe similar surgical retractor frames foruse with hooked members. Such a system is commercially available underthe trade name LoneStar Retractor System™.

A surgical drape having a central open ring for insertion over knownsurgical retractors is commercially available from Becton Dickinson ofFranklin Lakes, N.J. under the tradename Vidrape®. Relevant minimallyinvasive methods and devices for heart surgery are described in U.S.Pat. No. 5,452,733; U.S. patent application Ser. No. 08/163,241, nowU.S. Pat. No. 5,571,215, filed Dec. 6, 1993; U.S. patent applicationSer. No. 08/194,946, now U.S. Pat. No. 5,501,698, filed Feb. 11, 1994;U.S. patent application Ser. No. 08/227,366, now U.S. Pat. No.5,588,949, filed Apr. 13, 1994; and U.S. patent application Ser. No.08/486,941, now U.S. Pat. No. 5,799,661, filed Jun. 7, 1995, the fulldisclosures of which are incorporated herein by reference.

SUMMARY OF THE INVENTION

In a first aspect, the present invention provides a retractor forproviding surgical access to a body cavity of a patient through apassage in tissue. The retractor comprises an anchoring frame having anupper surface, a lower surface, and an opening therethrough whichdefines an axial axis. The anchoring frame is positionable through thepassage into the body cavity. A flexible tensioning member is attachedto the anchoring frame and extendable from the frame out of the bodythrough the passage. The tensioning member is selectively tensionable tospread the tissue radially outwardly from the axial axis. Hence, it isthe tension imposed on the flexible tensioning member which effectsretraction of the tissue, rather than relying on the structuralintegrity of a tubular structure such as a trocar sheath.

Generally, an attachment mechanism on the tensioning member maintainstension so as to retract tissue from the passage. Hence, the tensioningmember need only be capable of withstanding and transferring the tensionimposed by the attachment mechanism, there being no need for a rigidstructure having sufficient hoop strength to maintain the tissue in theretracted position. The resulting surgical access window need not becompromised by any rigid lumen wall or rigid blade-type structure, andthe retraction load is distributed atraumatically over a wide area ofthe tissue by the flexible tensioning member.

Preferably, the anchoring frame will have a narrow profile configurationfor insertion through an incision into the body cavity, and will beexpandable to a wide profile configuration once inside the body cavity.The frame may comprise a variety of collapsible and expandablestructures, including a ring of resilient material which expands to thelarge configuration when released. The tensioning member is preferablyformed of a plurality of elongate tabs or strips of cloth, tape, cord,or strap material, ideally comprising an absorbent material such asgauze so as to absorb any fluids released by the tissue bordering thepassage. Alternatively, an elastomeric or semi-elastomeric sheet orstrip may be used.

In another aspect, the present invention provides a retractor forproviding surgical access into a chest cavity defined by a plurality ofribs. The ribs are separated by intercostal tissue and an intercostalwidth. The retractor comprises an anchoring frame which is insertableinto the chest cavity through a passage between two ribs, the framehaving an opening. A flexible tensioning member extends from at leasttwo opposing sides of the opening in the frame. The tensioning member isable to extend out of the chest cavity through the passage when theframe is within the chest cavity and the opening in the frame isgenerally aligned with the passage. The tensioning member may betensioned to spread the intercostal tissue outward toward the two ribs.Such a retractor is particularly well suited for forming an anteriormediastinotomy or small thoracotomy for use in a less invasive coronaryartery bypass grafting procedure or other cardiac procedure.

Generally, an attachment mechanism on the tensioning member maintainsoutward radial tension from outside the patient to hold the intercostaltissue in a retracted position. In some embodiments, the attachmentmechanism comprises an adhesive disposed on the tensioning member tofacilitate attachment to an outer surface of the patient's chest.Optionally, a surgical film may be adhered to the exterior of the chestsurrounding the passage to facilitate adherence of the tensioning memberto the chest wall. In alternative embodiments, the attachment mechanismcomprises a plurality of clasps or other coupling devices disposed aboutan outer ring structure which is positioned outside the body cavity.

In yet another aspect, the present invention provides an illuminatedretractor for providing surgical access to a body cavity of a patientthrough a passage in tissue. The retractor comprises an internal anchorhaving an opening, the anchor being insertable through the passage andinto the body cavity. A tissue restraining structure extends proximallyfrom the internal anchor for holding the passage open sufficiently toprovide direct visualization of the internal body cavity from outsidethe patient. Typically, an external anchor is spaced proximally from theinternal anchor on the tissue restraining member. An illuminating deviceis disposed adjacent to the opening in the internal anchor to facilitatevisualization of the cavity through the open passage.

In yet another aspect, the present invention provides a tissue retractorsystem for providing surgical access through an incision in tissue to abody cavity of a patient. The system generally comprises a retractor anda retractor delivery device. Specifically, the retractor comprises ananchoring frame having an opening, wherein the frame is restrainableinto a narrow profile to facilitate insertion of the frame into the bodycavity. The frame is expandable into a wide profile when inside the bodycavity. A flexible tensioning member extends from the frame adjacent tothe opening and is selectively tensionable to retract the tissueadjacent the incision, and is adapted to be secured in tension outsidethe body cavity.

The retractor delivery device comprises a device body having distal andproximal ends, and a pair of inward facing surfaces near the distal endwhich restrain a frame of the retractor therebetween to a small profile.A handle supports the inward facing surfaces from a proximal end. Anactuator may be provided on the handle to effect expansion of the framewithin the body cavity.

The present invention also provides a method for retracting tissue totemporarily widen a penetration into a body cavity, the methodcomprising positioning an anchoring frame against a tissue surfacewithin the body cavity adjacent to the penetration so that an opening inthe frame is aligned with the penetration. The frame has a width acrossthe opening which is wider than the penetration. A tissue restrainingmember extending from the frame out of the body cavity through thepenetration is tensioned so as to urge the tissue adjacent thepenetration outwardly.

In a further aspect, the present invention provides a method forperforming surgery on a patient's heart, the heart being disposed withina chest cavity defined by a plurality of ribs, the ribs being separatedby intercostal tissue and an intercostal width. The method comprisesinserting an anchoring frame into the chest cavity through an incisionbetween two ribs, wherein the frame has an opening and a width acrossthe opening wider than the intercostal width. Tension is then imposed ona plurality of flexible tabs extending from the frame adjacent to theopening so as to widen the incision. Surgery is then performed on theheart using instruments positioned through the widened incision.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a retractor system according to the principles of thepresent invention, the system including a retractor and an associateddelivery device.

FIG. 2 is a cutaway view of the retractor of FIG. 1 as used forretracting intercostal tissue from between ribs to provide access to thechest cavity.

FIG. 2A is a cutaway view of a surgical instrument positioned through atypical known trocar sheath.

FIG. 2B is a cutaway view of a surgical instrument positioned throughthe retractor of FIG. 1, showing the increased angulation andmaneuverability provided by the surgical access of the presentinvention.

FIG. 3 shows the retractor system of FIG. 1 with the retractorrestrained in a small configuration by the delivery device.

FIGS. 4-6 illustrate a method of using the retractor system of FIG. 1 toprovide surgical access to a body cavity.

FIGS. 6A-6C illustrate alternative delivery devices for use with theretractor of FIG. 1.

FIGS. 6D-6G illustrate an alternative retractor having grommets and anassociated delivery device, according to the principles of the presentinvention.

FIGS. 7-9A show alternative embodiments of tissue retractors accordingto the principles of the present invention.

FIGS. 10A-10E illustrate an alternative embodiment of a retractor systemaccording to the principles of the present invention and a method forits use.

FIG. 10F illustrates an alternative outer ring structure for use withthe retractor of FIG. 10A.

FIGS. 11A and 11B illustrate a retractor having illuminating fiberopticsdisposed about an internal anchoring ring to provide both illuminationand access to an internal body cavity, according to the principles ofthe present invention.

FIGS. 12A and 12B illustrate a method for using the retractor of FIG. 1for coronary artery bypass grafting, according to the principles of thepresent invention.

FIG. 13 illustrates a method of retracting tissue during treatment ofcardiac valve disease, according to the principles of the presentinvention.

DESCRIPTION OF THE SPECIFIC EMBODIMENTS

The devices and methods of the present invention are suitable forproviding access for a variety of surgical procedures within thecavities of the body. Such access is particularly advantageous duringminimally invasive and less invasive surgical procedures in whichsurgical instruments are introduced through an access window provided bythe retraction of tissue.

The present retraction methods and devices will find particular usewhere direct visualization into a body cavity through a percutaneouspenetration facilitates the surgical procedure. Alternatively, anendoscope, laparoscope, thoracoscope, or other visualization device maybe inserted through such an access window for telescopic or video-basedvisualization. Additionally, tissues and/or organs may be temporarilyextended through the access window to allow external manipulation duringtherapy. The retraction methods and devices of the present inventionwill thus find applications in providing surgical access to the pelvis,abdomen, thorax, and other body cavities, to facilitate surgicalintervention on the gall bladder, colon, reproductive organs, kidneys,liver, stomach, heart, lungs, and other body structures.

The present invention will find its most immediate application inless-invasive surgery of the heart, particularly in less-invasivecoronary artery bypass grafting, less-invasive valve repair andreplacement, and other cardiac procedures. Surgical access windowsprovided by the flexible tensioning member of the retractor of thepresent invention will easily flex to adapt to the minimally invasivetools used in less invasive bypass procedures, thereby allowing thesetools to be manipulated more easily and used at a wider range of anglesthan could be accommodated by the rigid and semi-rigid trocar sheathsand conventional rigid retractors of the prior art. By utilizing tensionin a flexible strap or tab, the intercostal tissue between ribs may beatraumatically retracted as widely as possible without inflicting agross displacement of the ribs and the resulting patient trauma.However, where greater access is desired and/or required, the retractionmethods and devices of the present invention may also be used incombination with the excision of costal cartilage or even a partialsternotomy or small thoracotomy to maximize the size of the open accessport.

Referring now to FIG. 1, a retraction system 10 comprises a retractor 12and a delivery device 14. Retractor 12 includes an anchor ring 16 fromwhich a plurality of flexible tabs 18 extend. An adhesive is coated overa portion of each of tabs 18, and a backing strip 20 removably coversthe adhesive to facilitate handling the retractor.

Anchoring ring 16 may be either rigid or flexible, but preferablycomprises a resilient material biased to form an annular ring shape. Avariety of other frame shapes might also be used, including C-shaped,U-shaped, rectangular, elliptical, triangular, parabolic, and optionallyincluding articulated or living hinge joints. In any event, theanchoring frame will have at least two sections separated by an openingor gap such that the frame may be placed through a passage in a bodywall into a body cavity and the two sections positioned on either sideof the passage with the opening therebetween aligned with the passage.The anchoring ring may optionally be made of a relatively high strengthpolymer such as Delrin™, nylon, high density polyethylene, and the like.Preferably, the anchoring ring comprises a high strength biocompatiblealloy, ideally being a superelastic alloy such as Nitinol®. Such analloy ring may be formed by welding, crimping the joint with a stainlesssteel tube, butt jointing with heat shrink tubing, or the like, the ringpreferably having a diameter between about 10 mm and 9 cm. The exemplaryannular superelastic alloy anchoring ring may be readily compressed to asmall configuration for insertion, will readily expand to the large openconfiguration shown in FIGS. 1-2 once inside the body cavity, and willwithstand the compressive loads imposed by flexible tabs 18 duringretraction of tissue as described hereinbelow.

The axial dimension of anchoring ring 16 is preferably minimized toprovide maximum open working area within the body cavity and to providemaximum maneuverability of instruments positioned through it. In anexemplary embodiment, the anchoring ring has an axial thickness of lessthan about 20 mm, and preferably less than about 10 mm.

Flexible tabs 18 preferably comprise elongate strips of an absorbentmaterial such as gauze, cloth tape, or the like. Such gauze tabs may beeasily looped over anchoring ring 16 and sutured, sewn, adhesivelybonded, heat sealed, or welded to themselves. Alternatively, tabs 18 maybe directly adhesively bonded to anchoring ring 16, may be molded intothe anchoring ring, or may have the anchoring ring woven into the tabmaterial. Use of an absorbent material allows the flexible tab to absorbblood and other fluids which might otherwise seep from the retractedtissue into the body cavity. Where absorbency is less important,flexible tabs 18 may be an elastomer or a flexible, deformable orresilient metal.

The adhesive behind backing strips 20 will generally comprise a medicalgrade adhesive suitable for attachment to human skin or to paper, cloth,metal or plastic surfaces, such as an acrylate or other suitableadhesive. Conveniently, attachment may be facilitated by the use of aplastic film adhered to the patient's chest prior to insertion of theretractor, allowing backing strips 20 to be affixed securely to theplastic film.

Delivery device 14 generally includes a distal end 22 and a proximal end24. The distal end includes inward facing surfaces 25 which releasablyrestrain the anchoring ring in a small profile configuration, while theproximal end 24 includes a handle 27 for manipulation of these inwardfacing surfaces. Handle 27 comprises a pair of finger loops which may beactuated by passing the thumb and a finger therethrough and separatingand/or bringing together the thumb and finger. Arms 29 extend distallyto support each of the inward facing surfaces, the arms being hinged toform jaws 31 which widen or narrow the distance between inward facingsurfaces 25 as handle 27 is actuated. Preferably, arms 29 are generallyU-shaped as shown, extending distally, turning outward, and returningproximally to inward facing surfaces 25. Optionally, a releasable detentor ratchet (not shown) between the handles helps restrain inward facingsurfaces 25 at their closest proximity.

A particularly advantageous use of the retractor of FIG. 1 for accessingthe chest cavity by retracting the soft intercostal tissue between ribswill be described with reference to FIG. 2. A chest wall W is defined bya plurality of ribs R separated by intercostal tissue T. Anchoring ring16 of retractor 12 is shown inserted through a passage P through thechest wall. As used herein, a passage means any opening, puncture, woundor incision through tissue to a body cavity, whether open or closed.Hence, passage P may comprise an incision, a mediastinotomy,thoracotomy, or other opening formed by the cutting or removal oftissue, bone, or cartilage, a percutaneous opening through tissue, orthe like. In any event, tabs 18 extend from the anchoring ring 16outward through passage P. An upper surface 17 of anchoring ring 16 isplaced against an inner surface S of chest wall W, while a lower surface19 is oriented into the chest cavity C.

As tabs 18 are highly flexible and formed from separate elongate strips,they retract little or no tissue from the passage P when loose. However,when tension is applied to tabs 18, that tension is transmitted alongthe tab to act in a radial outward direction 26 against the tissue whichborders the passage P. The transmission of tension through the flexibletabs results in a retraction of tissue from both outside and inside thebody cavity, without interrupting the passage with a rigid trocar sleeveor other rigid retracting structure. Adhesive 28 disposed on tabs 18conveniently allows the tissue to be held in the retracted position byaffixing the tabs to the surface of the chest or to another externalstructure.

Access to the interior of body cavity C is thus provided through thepassage P by retracting tissue so as to form an open window. Tabs 18 areradially opposed, so that opposing radial tensions 26 help to holdanchoring ring 16 in alignment with the open window, and also so thattissue is retracted in opposite directions. Thus, access to the bodycavity is provided through an opening 30 in anchoring ring 16, which ispreferably larger than the open passage to prevent any interference, andpreferably wider than an intercostal width between adjacent, unretractedribs.

The improved access and visualization provided by the retractor of thepresent invention is seen most clearly in FIGS. 2A and 2B. Known trocarsheath 2 has a structural lumen 4 which must have walls of sufficientrigidity and thickness to retract intercostal tissue T. The length oflumen 4 is significantly greater than the thickness of chest wall W toensure that the lumen remains open when trocar sheath 2 is canted by amoderately angled surgical tool 6. The length of lumen 4 will also oftenbe increased to allow trocar sheath 2 to accommodate chest walls ofvarying thickness, further decreasing unimpeded angulation andmaneuverability of surgical tool 6. Clearly, direct visualization of aninternal procedure through lumen 4 of trocar sheath 2 would be highlyproblematic, even where surgical tool 6 is limited to the moderate angleshown.

In contrast to known trocar sheaths, retractor 12 provides a surgicalaccess window that accommodates less invasive surgical implement 3 at alarge angle relative to axial axis A, and with improved maneuverabilityand visualization. Tension in tabs 18 retracts intercostal tissue T frompassage P, and also pulls anchoring ring 16 firmly against the innersurface S of chest wall W. Not only does this avoid interference fromthe ring frame, but the tension of tabs 18 will actually compress thethickness of chest wall W adjacent passage P, further increasing therange of motion of implement 3. Finally, if even higher angles arerequired, the surgeon need only apply the force necessary to locallydisplace the tissue adjacent the angled tool, as the flexible tabs donot have a structural lumen which resists distortion. It can also beseen in FIG. 2B that visibility through a surgical access windowprovided by retractor 12 is substantially enhanced, particularly fromviewpoints which are at a substantial angle from axial axis A ofanchoring ring 16.

The deployment of retractor 12 using delivery device 14, will beexplained with reference to FIGS. 3-6. Preferably, delivery device 14 isinserted through opening 30 and jaws 31 are opened to align channels 34with ring 16. Ring 16 is positioned within channels 34 adjacent toinward-facing surfaces 25. The handle is then manipulated so that inwardfacing surfaces 25 engage the anchor ring to squeeze anchor ring 16 intothe elongate narrow profile configuration shown in FIGS. 3 and 4.Typically, delivery device 14 will releasably maintain the anchor ringin the narrow profile configuration during positioning. Anchoring ring16 is then inserted through incision I, preferably in an edgewiseorientation as shown in FIG. 4. As used herein, an edgewise orientationmeans that the axial axis of anchoring ring 16 is at an anglesubstantially less than 90 relative to, and preferably parallel to, thesurface of the body on which incision I is disposed.

Release of anchor ring 16 within the body cavity is most clearlyunderstood with reference to FIGS. 4A and 5. As shown in FIG. 4A, theanchoring ring may be expanded radially within the body cavity by movinginward-facing surfaces 25 away from one another. The delivery device iswithdrawn by first displacing it distally beyond detent 36. Jaws 31 arethen closed and the delivery device is withdrawn from incision I.

Prior to tensioning, opposed tabs 18 have little effect on the incisionI. Conveniently, the tabs may be simply pulled outward by hand totension tabs 18 and thereby retract the tissue adjacent to the incision.Anchoring ring 16 is drawn into engagement with the interior surface Sof the chest wall (as best seen in FIG. 2). When the tissue issufficiently retracted, backing strips 20 are removed and the tabsaffixed in place using the exposed adhesive, as illustrated in FIG. 6.The resulting open window 38 is of maximum size without any significantretraction of the ribs to accommodate various types and sizes ofinstruments and facilitating a high degree of angulation and motion ofsuch instruments. Furthermore, the chest wall tissue is compressedbetween the tabs 18 and ring 16, minimizing chest wall thickness toenhance instrument maneuverability. This contrasts with conventionaltubular ports, trocar sleeves, and other rigid retractors which have asignificant length extending both into and outside of the body cavity,hampering manipulation of instruments.

Referring now to FIGS. 6A and 6B, an alternative delivery device 31includes an inner support member 35 and a slidable outer member 37having inward facing surfaces 33. Outer member 37 may be retractedproximally relative to an inner support member 35 to allow ring 16 toexpand resiliently when released. The inner support member is thenwithdrawn from the expanded ring. A portion of tab 18 adjacent inwardfacing surface 33 is removed from FIG. 6A for clarity.

Referring now to FIG. 6C, a still further alternative delivery device 41includes fixed inward facing surfaces 43 on a distal bracket 45. Fixedsurfaces 43 are defined by a slot 47 in bracket 45, the slot accepting apair of opposing tabs 18. Tensioning of the tabs 18 which pass throughslot 47 collapses anchoring ring 16 to the narrow profile configurationduring insertion. Releasing the tension from outside the patient allowsthe anchoring ring 16 to expand resiliently.

A still further alternative delivery device 61 will be described withreference to FIGS. 6D-6G. This embodiment makes use of a retractorhaving tabs 63 with openings which are reinforced with grommets 65. Thegrommets facilitate holding the tabs with pin 67 of actuator 69. Theactuator is upwardly slidable relative to a pair of rollers 71 mountedto a handle 73. Tabs 63 are threaded around rollers 71 and grommets 65placed over pins 67. As seen most clearly in the front view of FIG. 6F,grasping handle 73 and drawing the actuator in the upward directionindicated will tension the tabs and compress ring 16. Rollers 71 mayoptionally rotate, or the tabs may slide over the roller's roundedsurface. In either case, the distance between the rollers need notchange. Hence, the portion of each roller which is adjacent to the otherroller defines an inward facing roller surface 75; and the anchoringring is restrainable in the narrow configuration by these inward facingroller surfaces when the tab is held under tension by pin 67.Alternatively, the grommets maybe disposed on separate tethers attachedto the ring, so that the tabs are used only for retraction of tissue.

Referring now to FIG. 7, an alternative embodiment of a retractoraccording to the principles of the present invention comprises aninternal anchoring ring 46 and a tissue restraining member comprising asingle-piece sheet 48, which may be flat, bowl-shaped or tubular,preferably comprising a thin semi-elastic polyethylene or urethanematerial. Adhesive backing 44 disposed on opposed extended tab 49provides an attachment mechanism to restrain the tissue in the retractedposition.

Referring now to FIG. 8, a still further alternative embodiment of thepresent retractor 50 comprises an outer ring 54, an anchoring ring 56,and tabs 58 coupled therebetween. Expansion mechanism 60 allows thediameter of outer ring 54 to be increased when knob 62 is turned,thereby tensioning tabs 58 when the anchor ring is in position. In anexemplary configuration, outer ring 54 is a split ring with overlappingportions 54a, 54b. Expansion mechanism 60 comprises a clamp for clampingoverlapping portions 54a, 54b in position; e.g., knob 62 may be a setscrew which engages overlapping portion 54a and urges it against portion54b. Alternatively, expansion mechanism 60 may mechanically expand ring54, e.g., by a pinion gear attached to knob 62 which engages a series ofteeth along one of overlapping portions 54a, 54b so as to expand ring 54when the knob is turned.

In a further embodiment, shown in FIG. 9, a balloon retractor 70includes an outer balloon ring 64, an anchor ring 66, and a tubularelastomeric tissue restraining member 68 extending therebetween, as seenretracting tissue in chest wall W. Balloon ring 64 is generallyelastomeric or semi-elastomeric, and preferably comprises baffles 72 togive the balloon greater structural integrity and stiffness. The size ofthe balloon ring (and hence the tension on restraining member 68) may bevaried using inflation pump 74 and temporarily fixed with stopcock 76.As the diameter of the balloon ring expands under greater inflationpressure, tab 68 increasingly retracts tissue between ribs R.

Referring now to FIG. 9A, a still further embodiment of the presentretractor 109 includes a polymeric anchoring ring 111 and a plurality ofadhesive backed flexible tabs 105. Polymeric anchoring ring 111 includesrigid sections 111a separated by opposed living hinges 107, preferableformed by locally tapering the thickness of the ring material.Optionally, the anchoring ring is machined from nylon, Delrin™, a highdensity polyethylene, or another relatively high strength polymer.Living hinge 107 facilitates compressing the prosthesis into a narrowdiameter configuration by promoting localized bending, and adhesivebacked tabs 105 may optionally be attached to the ring by wrapping thetab about the ring so that the tab adhesive adheres to the ring surface.Living hinges 107 may alternatively comprise pin joints or other hingesto provide pivotal motion between sections 111a.

Referring now to FIG. 10A, a still further embodiment of the presentretractor 81 comprises an anchoring ring 82, tabs 84, and an outer ring86. Tabs 84 have a tissue restraining portion 98 from which tethers 96extend. Tethers 96 pass through slots 99 in outer ring 86, the tetherstensioning tissue restraining portions 98 so as to retract tissue fromthe passage. Conveniently, slots 99 are provided with catches, clamps,or ratchets 100 to engage each tether 96 so as to restrain the tissue inthe retracted position. These ratchets facilitate expansion of theaccess window by manually pulling tethers 96 relative to outer ring 86.

Referring now to FIGS. 10B-10E, a particularly advantageous retractorsystem 80 comprises retractor 81 and a delivery device including anobturator 88 having a longitudinal channel 89 with inward facingsurfaces 90 which restrain the anchor ring therebetween. An actuationhandle 92 is located on the proximal portion of the delivery device.

Once the obturator is inserted through the chest wall W, depressingbutton 94 of handle 92 advances a push rod 95 distally to expel anchorring 82 distally from the obturator. The individual length of tabs 84 isselected to promote alignment between the anchoring ring opening and thepassage through the tissue. Tabs 84 again include a tissue restrainingportion 98 from which tethers 96 extend. Tethers 96 initially extendfrom tabs 84 through slots 99 in outer ring 86, and back to the proximalhandle 92 of the delivery device. Thus, proximally retracting obturator88 relative to the outer ring 86 pulls anchor ring 82 against chest wallW and tensions tethers 96. Tethers 96 are attached to proximal handle 92by anchors 101 which are held within apertures 103 in proximal handle92, as shown in FIG. 10D. Rotation of knob 130 of proximal handle 92releases anchors 101 from apertures 103 to decouple tethers 96therefrom, allowing the delivery device to be removed from theretractor, leaving an open access port through the retractor as shown inFIG. 10A.

Referring now to FIG. 10F, an alternative outer ring 102 includes aplurality of temporary suture retainers 104 useful in maintaining sutureorganization in surgical procedures that require a large number ofsutures. Retainers 104 may comprise a plurality of radially-orientedslots between 4 and 30 in number configured to frictionally retain asuture thread placed in the slot. Alternatively, retainers 104 may behooks, eyelets, clamps, cleats, or the like.

The retractors of the present invention are particularly advantageouswhen used with direct visualization through an open window, resulting infaster and more cost efficient less invasive surgical procedures. Suchdirect visualization reduces or avoids the necessity to resort tothoracoscopes and other remote imaging modalities. However, thiselimination of the scope from the interior body cavity may alsoeliminate the primary source of illuminating light, the illuminationfiberoptics which are generally provided with such scopes. Therefore,the present invention further provides illuminated retractors, anexemplary embodiment being illustrated in FIGS. 11A and 11B.

Illuminating retractor 110 includes an anchoring ring 112 and aplurality of tabs 114 as described above, and also includes a pluralityof illuminating optical fibers 116 disposed about the anchoring ring andhaving distal ends 117 pointing distally into the body cavity from thelower surface of anchor ring 112. Advantageously, optical fibers 116extend independently in the proximal direction along the tabs,minimizing any reduction in the size of the opening in the body wall.These independent fibers are then combined together in a cable 119 ashort distance from ring 112 and attached to one or more opticalcouplers 118. Cables 119 may or may not be mounted to one or more tabs114.

The illuminating ends 117 of optical fibers 116 are generally orienteddistally into the body cavity, and may be molded into the anchoringring, bonded onto an inner or outer surface of the anchoring ring, ormay terminate along tabs 114 adjacent to the anchoring ring. Similarly,the dispersed fiberoptics along tabs 114 might be woven into a textiletab, imbedded within a polymer tab with reinforcing or malleable membersfor optimal light positioning, or be bonded on an inner or outer surfaceof the tab. Advantageously, the dispersion of the optical fibers acrossthe tab not only minimizes the profile of the fibers, but also helps tomaintain the flexibility of the tabs.

The use of retractor 12 during a coronary artery bypass graftingprocedure is illustrated in FIGS. 12A and 12B. As more fully explainedin U.S. Pat. No. 5,452,733, previously incorporated herein by reference,an exemplary bypass procedure involves harvesting of the internalmammary artery IMA and joining it with the diseased coronary artery,here the left anterior descending coronary artery LAD. Optionally, aplurality of conventional trocar sheaths, may be used in combinationwith the retractor 12 of the present invention. Alternatively, thepresent method for coronary artery bypass grafting may be performedentirely through surgical access windows provided by one or moreretractors according to the present invention.

Internal mammary artery IMA may be joined to incision 122 in thecoronary artery LAD by a variety of conventional techniques, includingsuturing, laser welding, tissue gluing, microstapling, and the like.When conventional suturing techniques are used, a length of suture 124having a needle 126 on at least one end may be manipulated using forceps128 either inside the chest cavity, or outside the chest cavity directlyadjacent retractor 12. In either case, forming the anastomoses isgreatly facilitated by the high degree of instrument mobility and by thedirect visualization of the procedure provided by retractor 12.

Referring now to FIG. 13, a retractor 130 similar to the embodimentshown in FIG. 10A and having suture organizing outer ring 102 asillustrated in FIG. 10F is particularly advantageous for use in a lessinvasive surgical procedure for repair or replacement of a heart valve,for example a mitral valve MV via the left atrium LA. Access to theheart H through the window provided by retractor 130, and/or throughtrocar sheaths 120 is improved by deflating right lung L. As more fullyexplained in U.S. Pat. No. 5,972,030, the full disclosure of which isincorporated herein by reference, a valve prosthesis 131, such as amechanical heart valve or annuloplasty ring, may be positioned throughretractor 130 into the heart and secured at the native valve position torepair or replace the native valve. A plurality of sutures 132 are usedto secure the prosthesis in the heart, and each suture may be drawn outof the chest and retained in suture organizing outer ring 102 asdescribed above in connection with FIG. 10F to prevent tangling anddisorganization.

Although the foregoing invention has been described in some detail byway of illustration and example, for purposes of clarity andunderstanding, certain changes and modifications will be obvious tothose with skill in the art. For example, both the outer ring and theanchoring structures may take a variety of forms, including articulatedlinkages, expandable balloons, multiple layer coils, and the like. Thus,the scope of the present invention is limited solely by the followingclaims.

What is claimed is:
 1. An illuminating retractor for providing surgical access to a body cavity of a patient through a passage in tissue, the retractor comprising:a flexible internal anchor having an opening, the internal anchor being insertable through the passage and into the body cavity; a tissue retracting structure extending proximally from the internal anchor for holding the passage open sufficiently to provide direct visualization of the internal body cavity from outside the patient; an external anchor on the tissue restraining structure spaced proximally from the internal anchor; and an illuminating device disposed at the opening in the internal anchor to facilitate visualization through the open passage.
 2. An illuminated retractor as claimed in claim 1, wherein the illuminating device comprises a plurality of optical fibers having distal ends oriented toward the body cavity.
 3. An illuminated retractor as claimed in claim 2, wherein the plurality of optical fibers are independent of the tissue restraining structure.
 4. An illuminated retractor as claimed in claim 2, wherein the plurality of optical fibers are mounted to the tissue restraining structure.
 5. An illuminated retractor as claimed in claim 1, wherein the internal anchor comprises an anchoring frame having an opening, the tissue restraining structure comprises a liner extending from the frame at least partially around the opening, and the external anchor is configured to maintain outward radial tension in the liner.
 6. An illuminating retractor for providing surgical access to a body cavity of a patient through a passage in tissue, the retractor comprising:a flexible internal anchor having an opening, the internal anchor being insertable through the passage and into the body cavity; a flexible tissue restraining structure extending proximally from the internal anchor, the tissue restraining structure configured to be secured in tension outside the body cavity so as to hold the passage open sufficiently to provide direct visualization of the internal body cavity from outside the patient; and an illuminating device disposed at the opening in the internal anchor to facilitate visualization through the open passage. 